Provider Demographics
NPI:1558425207
Name:SHOSHONE TRIBE EARLY INTERVENTION PROGRAM
Entity Type:Organization
Organization Name:SHOSHONE TRIBE EARLY INTERVENTION PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:307-332-3516
Mailing Address - Street 1:PO BOX 610
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE
Mailing Address - State:WY
Mailing Address - Zip Code:82514-0610
Mailing Address - Country:US
Mailing Address - Phone:307-332-3516
Mailing Address - Fax:307-332-9116
Practice Address - Street 1:90 ETHETE ROAD
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE
Practice Address - State:WY
Practice Address - Zip Code:82514-0610
Practice Address - Country:US
Practice Address - Phone:307-332-3516
Practice Address - Fax:307-332-9116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)